Hysteria

In contemporary usage, the name hysteria is given to a form of mental illness characterized by the exhibition of bodily signs such as paralysis or spasmodic movements and by complaints about the body, such as anesthesia or pain. The terms conversion hysteria and dissociative reaction are other names given to these phenomena. Bodily communications indistinguishable from those typical of hysteria may also be present in individuals diagnosed as hypochondriacal, neurasthenic, or schizophrenic, and sometimes in so-called normal persons as well.

Historical overview of the problem. The group of phenomena we now call hysteria and regard as a type of mental disease has been known since antiquity. Its many interpretations, during different historical periods, reflect the varied cultural concepts for explaining bodily illness and social deviance.

The term hysteria comes from the Greek word hystera, which means the womb or uterus. Hippocrates thought that the uterus was a free, peregrinating organ and that its wandering about the woman’s body caused hysteria. Although he considered it a distinct, organic disease, he may have sensed its relation to the sexual passions, for he recommended marriage as the best remedy. The notion that hysteria was a condition limited to women was thus firmly established and was not seriously challenged until the latter half of the nineteenth century by Charcot (Zilboorg 1941).

During the first ten centuries of Christianity, with medical thought stagnating under the authoritarian influence of Galenic concepts, most cases of hysteria were probably mistaken for various bodily diseases. During the Middle Ages, as the attitude toward sickness changed from naturalistic to demonotheologic, many cases of hysteria, and undoubtedly of organic disease too, were interpreted as manifestations of witchcraft.

With the flowering of empiricism and science during the Renaissance, hysteria was again rediscovered as a disease. It is interesting that in the eighteenth century its main cause was attributed to emotions, passions, and human suggestibility, and in the early nineteenth, to organic dysfunction. It fell to Charcot, Janet, and Freud to clarify the distinction between neurological illness and hysteria. They showed that hysteria is a condition resembling physical disease that occurs in persons with healthy bodies. If this was hysteria, it is evident why it had to be distinguished from malingering. In theory, this was accomplished by defining hysteria as the unconscious imitation of illness, and malingering as the conscious imitation of it. In practice, the distinction was less easy to make.

It is only a small step from the psychoanalytic view of hysteria, which regards it as a form of illness, albeit without physical causation, to the communicational view of hysteria, which regards it as a form of communication—specifically, as the language of illness. The implications of the various concepts of hysteria for its epidemiology and therapy will be discussed later.

What is hysteria? What kind of “thing” is it? The most popular view today is that hysteria is a disease. Some consider it an organic disease; others, a mental disease.

Organic theory. The idea that hysteria is an organic disease has the merit of being logical. After all, the hysteric acts sick and looks sick; he is manifestly disabled; and he says he is ill. Supporters of this view argue that people have been disabled by many conditions—for example, diabetes and neurosyphilis—that were not understood as diseases with specifiable physicochemical causes and disturbances until recent times. They claim that hysteria is another such disease: we understand only its “mental symptoms,” but in time will discover its physicochemical cause (Szasz 1961, pp. 91-93).

Thus, according to the organic theory of hysteria, the condition is basically similar to diseases of the central nervous system, such as multiple sclerosis. In this frame of reference, hysteria is a disease that happens to a person: he suffers from it and may be cured of it. Logically, this is a sound position. Factually, I consider it false.

Psychopathological theory. Few behavioral scientists accept the theory of the organic causation of hysteria. Those who consider hysteria an illness usually qualify it as a mental illness. Its pathology, therefore, is sought not in the patient’s brain or body but in his psyche; hence we have various hypotheses about the so-called psychopathology of hysteria. The specific content of these hypotheses varies with the theories of particular schools of psychodynamics. There is general agreement, however, that hysterical bodily signs represent an unconscious conversion of repressed ideas, feelings, or conflicts into symptoms.

Thus, the psychopathological theory of hysteria also regards this condition as a disease, but with psychological causes rather than physiological. This explanation is weak logically (Ryle 1949) and is not adequately testable.

Communicational theory. Finally, there is the communicational theory of hysteria. It is based on the proposition that not all types of disability should be classified as illness; and, further, that so-called hysterical symptoms are a form of communication and game playing. Hysteria is a game with a theme of helplessness and helpfulness. The hysteric acts disabled and sick: however, his illness is not real, but is merely an imitation of a bodily illness. Because the hysteric impersonates the sick role, the result is genuine disability. But if we call this condition an illness, we use this term metaphorically, whether or not we realize it (Szasz 1961, pp. 259-279).

Thus, according to the communicational approach to hysteria, the phenomena that the patient presents are examined and interpreted not only in the context of his past, but in the context of his total human situation. Through body language, the hysteric communicates with himself and others —but especially with those who are willing, and often eager, to assume the role of being protective and controlling. This explanation is logically sound and testable. To date, I consider it our most adequate theory of hysteria.

It is appropriate to raise certain questions now, such as: Is hysteria the same as it has always been or has it changed during the past fifty to eighty years? Is it more, or less, common today than it was in the past? Our answers will depend, in part, on our concept of hysteria.

It has been widely suggested (for example, by Chodoff 1954; Wheelis 1958; and others) that hysteria was more common in Austria toward the end of the last century than it is in America today. The evidence for this view is unconvincing. What has changed, without any doubt, is the sociology of medical practice. Thus, in the Paris or Vienna of the 1880s, persons with bodily complaints were seen by general practitioners or neurologists. The doctor’s main task was to make a differential diagnosis between organic disease and conversion hysteria (and malingering). Today, such patients still seek the help of the general practitioner and the medical specialist. In the meantime, however, there developed a new medical specialty: psychiatry. Because hysterical patients consider themselves medically, not mentally, ill, they do not usually consult psychiatrists.

As psychiatry became a separate discipline, hysteria (and other mental disorders) became a specifically psychiatric diagnosis (much as, for example, myelogenous leukemia is a specifically hematologic diagnosis). It is expected, therefore, that this diagnosis will be attached to so-called psychiatric patients. However, persons who consult psychiatrists voluntarily or who are committed to their care involuntarily rarely suffer from what appears to be bodily illness; more often, they feel anguished or they annoy others. Thus, it is true that among the contemporary psychiatrist’s patients hysteria is not a conspicuous complaint. But this does not mean that the incidence of hysteria in the population at large has decreased. I believe it has not.

The evidence suggests that hysteria is as common as ever, and perhaps more so. To be sure, as we have noted, persons who imitate illness, or who communicate with others in the language of illness, do not crowd the psychoanalyst’s private office. Instead they go where—to paraphrase the signs that announce Aqul se habla espanol or lei on parle frangais—the sign proclaims, We speak the language of illness. Where are such signs displayed? In the offices of general practitioners, internists, dermatologists, neurologists, and so forth; in medical clinics, and especially in famous diagnostic centers; in clinics where compensation for illness is awarded, such as those operated by the Veterans Administration; and in the offices of lawyers and in courts, where money damages may be sought and obtained for illness, both organic and mental, real and counterfeit.

Because of these radical changes during the past half century in the sociology of medical and psychiatric practice, I consider it misleading to speak simply of the incidence of hysteria. We must specify the particular situation, with respect to the social identity of both the observer and the observed, in which the incidence of the disorder is to be established.

Working as a physician, Freud developed his theory of hysteria to account for, and to help him cope with, some of the practical problems that faced him. What were these problems? Here is a typical example of one from Breuer and Freud’s classic work, Studies on Hysteria:

In the autumn of 1892, I was asked by a doctor I knew to examine a young lady who had been suffering for more than two years from pains in her legs and who had difficulties in walking…. All that was apparent was that she complained of great pain in walking and of being quickly overcome by fatigue both in walking and… standing, and that after a short time she had to rest, which lessened the pains but did not do away with them altogether…. I did not find it easy to arrive at a diagnosis, but I decided for two reasons to assent to the one proposed by my colleague, viz. that it was a case of hysteria. (Breuer & Freud [1893-1895] 1955, pp. 135-136)

What was wrong with this young woman? Because of the absence of neurological and other medical illness, and for certain other reasons as well, Freud concluded that she suffered from the disease called hysteria. How is this disease brought into being? This was Freud’s explanation:

According to the view suggested by the conversion theory what happened may be described as follows: She repressed her erotic idea from consciousness and transformed the amount of its affect into physical sensations of pain.—We may ask: What is it that turns into physical pain here? A cautious reply would be: Something that might have become, and should have become, mental pain. If we venture a little further and try to represent the ideational mechanism into a kind of algebraical picture, we may attribute a certain quota of affect to the ideational complex of these erotic feelings which remained unconscious, and say that this quantity (the quota of affect) is what was converted. (Breuer & Freud [1893-1895] 1955, p. 166)

Etiology. The mechanism of the pathogenesis of hysteria was subsequently elaborated and refined by Freud and other psychoanalysts and came to include certain other features. According to Glover (1939, pp. 140-149), the following etio-logical factors are responsible for the occurrence and specific content of conversion symptoms:

(1)Somatic compliance. Symptoms are localized in accordance with the distribution and fixation of body libido; body parts or organs, overli-bidinized by previous organic disease or continuous hyperfunction, become the media of expression.

(2)Frustration, introversion, and regression. If there is frustration of instinctual drives in adult life, the libido tends to turn from reality to fantasy. Fantasy is subject to the laws of regression.

(3)Reactivation of the Oedipus situation. Infantile fantasies, especially those associated with the Oedipus complex, are reactivated through regression.

(4)Breakdown of repression. Repression, faulty to begin with, cannot cope with the additional charge of the reactivated infantile fantasies. The defense crumbles and the repressed content breaks through: the return of the repressed.

(5)Symptom formation through displacement and symbolization. The specific form of conversion symptoms is determined partly by the degree of genital symbolization of various parts (that is, to what extent, for any particular person, parts of his body resemble the genital organs); and partly by the extent of the person’s unconscious identification with his incestuous objects (that is, parents or siblings).

The result is an inhibition or exaggeration of bodily functions, giving rise to crippling or painful symptoms. These constitute a somatic dramatization of unconscious fantasies.

The psychoanalytic theory of hysteria contains rudimentary suggestions for a communicational approach to this phenomenon. However, a systematic account of hysteria as language or communication was not developed until recently (Szasz 1961, pp. 115-163). To understand this view requires acquaintance with certain technical concepts, which I shall summarize here.

Anything in nature may or may not be a sign, depending on a person’s attitude toward it. A physical thing—a chalk mark, a dark cloud, a paralyzed arm—is a sign when it appears as a substitute for the object for which it stands, with respect to the sign user. The three-part relation of sign, object, and sign user is called the relation of denotation.

Classes of signs. Three classes of signs may be distinguished: indexical, iconic, and symbolic, or conventional, signs.

In the indexical class belong signs that acquire their sign function through a causal connection. For example, smoke is a sign of fire and fever a sign of infectious disease.

In the iconic class belong signs that acquire their sign function through similarity. For example, a photograph is a sign of the person in the picture; a map is a sign of the territory it represents.

In the third class, symbolic, or conventional, signs, belong signs that acquire their sign function through arbitrary convention and common agreement—for example, words and mathematical symbols. Symbols do not usually exist in isolation, but are coordinated with each other by a set of rules called the rules of language. The entire package, consisting of symbols, language rules, and social customs of language use, is sometimes referred to as the language game. [See Semantics and semiotics].

Hysteria and the language of illness. Communicational situations may comprise one, two, three, or a multitude of people. A semiotic and game-playing view of hysteria (Szasz 1961, pp. 115-293) does not imply a purely social approach and hence a neglect of the intrapersonal dimension of the problem.

For example, hysteria (and other so-called mental illnesses) may occur in a one-person situation. An individual who feels pain in his abdomen and concludes, falsely, that he suffers from acute appendicitis illustrates this phenomenon. Such a person fools himself, not others. He plays a game by disguising his personal problem as a medical disease. The advantage derived from such a one-person game corresponds closely to the psychoanalytic idea of primary gain.

However, since people generally do not live in isolation, the interpersonal and social aspects of hysterical (hypochondriacal, neurasthenic, etc.) communications are of great importance. Indeed, it is the complexity of communications among people that accounts for much of the complexity of hysteria as a so-called clinical syndrome (Szasz 1957).

Thus, if a person complains to his physician of abdominal pain and insists that it is due to an inflamed appendix, even though there is no other evidence to support this view, first his interpretation will be discredited, and then he himself will be discredited. The more he enlarges the social situation where he makes this claim, the more he risks being seriously discredited (for example, by being labeled schizophrenic and committed to a mental hospital). In a sense, such a person plays a game of fooling others. To the extent that he succeeds and is accepted as sick, he derives an advantage from his strategy. This advantage corresponds closely to the psychoanalytic idea of secondary gain.

From a communicational point of view, the traditional problem of differentiating hysteria from organic disease becomes one of distinguishing iconic signs from indexical ones. The physician and psychotherapist observe signs, not diseases—the latter being inferences drawn from the former. Thus, an analysis based on sign discrimination is likely to be more testable, as well as more serviceable, than one based on disease differentiation.

How, then, do we distinguish indexical signs from iconic signs? This is done by ascertaining whether the sign is “given” by a person or “given off” by him. Iconic signs resemble conventional ones because both are manufactured, more or less deliberately, by a person; indexical signs are passively given off, rather than actively emitted, by the signaling organism.

Thus, if a person complains of abdominal pain, our question is not, Is he suffering from acute appendicitis or from hysteria? but rather, Is the pain an indexical sign of an inflamed appendix or an iconic sign of it? Obviously, it could be both at once. It is therefore never possible to make a “diagnosis” of hysteria by ruling out organic illness, nor a diagnosis of organic illness by ruling out hysteria. Instead, in doubtful cases, both patient and physician must decide whether to approach the sign as though it were indexical, signaling a disease of the body, or as though it were iconic, signaling a complaint about the self and others. The former approach requires adequate medical investigation, the latter, meaningful communication.

Implications of a communicative view. I shall now list the major implications of a communicative view of hysteria:

First, hysteria is a particular type of forgery—namely, impersonation of the sick role.

Second, hysteria is a particular dialect of the language of sickness and health. It is a form of communication especially appropriate to the medical, or related, situation in which a person defines himself and is accepted as sick or disabled; those about him are then defined complementarily as physicians or healers.

Third, the language of hysteria is composed of iconic signs, is nondiscursive (Langer 1942), and hence ambiguous. The meaning the sender intends to convey is easily misunderstood or misinterpreted by the receiver. This may be useful to the sender, the receiver, or both.

Fourth, the language of hysteria cannot convey information accurately, but can induce feeling and promote action in others. It is thus a type of rhetoric, that is, a method of persuasion or coercion.

Rhetoric of hysteria. It is useful to distinguish between two types of communication—dialectical and rhetorical. The former term refers to attempts to explain something; the latter refers to efforts to convince someone.

I have suggested that hysteria is a form of rhetoric. I now wish to substantiate this view.

What does the hysteric do? Why is he called by this name? He complains of pain and suffering; he exhibits bodily signs suggesting that he is sick; and, finally, he adopts a general style of communication that enables him to arouse and alarm those about him. He does this by confronting them with desperate situations that seem to require immediate intervention.

Why does the hysteric do this? Freud and other psychoanalysts have suggested the main answers. However, I think there are two additional reasons. One is that the subject knows that he has no legitimate ground for making demands on others: he therefore resorts to the language of illness. The other is that he knows that the language of hysteria is more effective as a rhetorical device than everyday speech. The reason for this is simple.

To identify a person, we use his photograph or fingerprint, not a verbal description of his appearance. The hysteric uses an analogous principle. If one person seeks the attention, interest, or help of another individual, he can achieve these aims best by a dramatic display of messages that say, in effect, “I am sick! I am helpless! You must help me!” This can be accomplished more effectively by displaying the image or the icon of illness—an apparently sick body—than by asserting, calmly and in everyday language, the suspicion that one feels ill and perhaps ought to see a doctor. If one picture is worth a thousand words, one hysterical symptom is worth two thousand. Herein lies the rhetoric of hysteria.

Only in organic medicine can we speak meaningfully of treatment: a disease can be cured; a person can only be changed.

Does the hysteric want to be changed? Often he does not. Instead, he wants to change others, so that they will comply with his wishes more readily. This insight, poorly understood and even more poorly articulated, led many physicians to conclude that such patients were “social parasites” who “would … steal anything conveniently within reach, lie, cheat, make work and trouble for others …” (Rogues de Fursac 1903, p. 317 in 1920 edition.).

Because hysteria is a form of rhetoric, it often evokes counter-rhetoric in response. The patient tries to coerce through symptoms; the physician tries to coerce through hypnosis. The result is often a mutually antagonistic, coercive relationship; sometimes the patient dominates, sometimes the doctor, and often the contest ends in a draw.

It is also possible for the physician, knowingly or unwittingly, to treat the hysteric as if he (or she) were ill. Such a physician accepts the patient’s communications couched in the language of illness and replies in the same idiom. In the past, this took the form of mythical diagnoses, like uterine retroflexion or focal infection, and of surgical treatments whose value lay not in correcting abnormal bodily function but in symbolically legitimating the patient’s sick role.

Today, this type of conversation between patient and doctor, employing the language of illness, can be carried on with greater ease than ever, since modern tranquilizing drugs constitute a socially accepted form of medical treatment for nonexistent medical illnesses. By prescribing such drugs, the physician acts as if he accepts the hysteric as genuinely sick; at the same time, he tries to repress (alter) the symptoms. This may be expedient for the therapist and acceptable to the patient.

Why, then, should we not rejoice in this modern approach to the “treatment” of hysteria (and other mental disorders)? Because we must remember that every “mental” symptom is a veiled outcry of anguish. Against what? Against oppression, or what the patient experiences as oppression. The oppressed speak in a million tongues—the myriad symptoms of hysteria (and mental illness). They make use of all the well-tried languages of illness and suffering and constantly add tongues newly created for special occasions. They need these mar-velously complicated linguistic devices, for, at a single stroke, they must reveal and conceal themselves.

What of the psychiatrist or of others who wish to help such a person? Should they amplify the dissent and help the oppressed shout it aloud? Or should they strangle the cry and reoppress the fugitive slave? This is the psychiatric therapist’s moral dilemma (Szasz 1964).

It is such considerations that led Freud to develop the psychoanalytic method and others to refine it. The psychoanalytic therapy of hysteria was thus a moral, rather than a purely medical, breakthrough in psychiatry.

Because hysteria is a form of rhetoric, it tends to evoke one of two responses: acceptance or rejection of the idea (and action) that the patient seeks to impose on the doctor. Either course leads to subsequent difficulties: the first to the doctor’s inability to treat the patient, the second to an antagonistic relationship between patient and physician. Psychoanalysis seeks to avoid this interpersonal impasse by offering the patient another level of discourse. It substitutes dialectic for rhetoric and discursive language for nondiscursive.

Abse, D. Wilfred 1959 Hysteria. Volume 1, pages 272-292 in American Handbook of Psychiatry. Edited by Silvano Arieti. New York: Basic Books. → A useful general work on hysteria.

Breuer, Josef; and Freud, Sigmund (1893-1895) 1955 The Standard Edition of the Complete Psychological Works of Sigmund Freud. Volume 2: Studies on Hysteria. London: Hogarth; New York: Macmillan. → First published in German.

Chodoff, Paul 1954 A Re-examination of Some Aspects of Conversion Hysteria. Psychiatry 17:75-81.

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hysteria

hysteria Since the rise of the so-called ‘psychodynamic psychiatries’ early in the twentieth century, hysteria has been regarded as a psychological malady par excellence. Through most of its long medical history, however, the concept was interpreted as a disorder purely of the body, with specific causes, symptoms, and treatments that were organic.

The modern English word ‘hysteria’ derives from the Greek ‘hystera’ — uterus — which in turn derives from the Sanskrit word for stomach or belly. Inherent in these simple etymological facts is the meaning of the earliest views on the nature and origin of the disease. According to some historians, an Egyptian medical papyrus dating from around 1990 bc — one of the oldest surviving documents known to medical history — records a series of curious behavioural disturbances in adult women. As the ancient Egyptians interpreted it, the cause of these abnormalities was the movement of the uterus, which they believed to be an autonomous, free-floating organism that could move upward from its normal pelvic position. Such a dislocation, they reasoned, applied pressure on the diaphragm and gave rise to bizarre physical and mental symptoms. Egyptian doctors developed an array of medications to entice the errant womb back down into its correct position. Foremost among these measures were the vulvar placement of aromatic substances to draw the womb downward, and swallowing foul-tasting substances to repel the uterus away from the upper parts.

Hysteria in ancient history

This ancient Middle Eastern source furnished the basis for classical Greek medical and philosophical theories of hysteria. The ancient Greeks adopted the notion of the migratory uterus and embroidered upon the connections between hysteria and sexual dissatisfaction. In an often-cited passage in the Timaeus, Plato wrote colourfully about the vagaries of female reproductive physiology: ‘the animal within them [women] is desirous of procreating children, and when remaining unfruitful long beyond its proper time, gets discontented and angry, and wandering in every direction through the body, closes up the passages of the breath, and by obstructing respiration, drives them to extremity, causing all varieties of disease …’Various texts of the school of Hippocrates, from the fifth century bc onward, explain similarly that a mature women's deprivation of sexual relations causes a restless womb to move upward in search of gratification. As the female reproductive parts move or function irregularly — ascending or descending, convulsing or prolapsing — they cause dizziness, motor paralyses, sensory losses, and respiratory distress (including globus hystericus, the sensation of a ball lodged in the throat) as well as extravagant emotional behaviours. Ancient Greek therapies included uterine fumigations, the application of tight abdominal bandages, and a regular regimen of marital fornicatio.

Traditional historical accounts of the disease observe that ancient Roman physicians, too, wrote about hysteria. With the growth of anatomical knowledge, the literal hypothesis of the morbidly wandering womb became increasingly untenable. However, Roman medical authors continued to associate hysteria exclusively with the female generative system. The principal causes of hysterical disorders, they conjectured, were ‘diseases of the womb’ and disruptions of female reproductive biology, including amenorrhea, miscarriage, premature births, and menopause. Galen of Pergamon formulated a particularly popular theory tracing the origins of the malady to the retention of excessive menstrual blood. Engraved in the Corpus Hippocraticum and the Galenic writings, these hypotheses formed a medical ideology that remained influential for millennia of medical history. Descriptive and theoretical details evolved, but the basic doctrine of gynaecological determinism — the crux of the classical heritage in the history of hysteria — endured until remarkably late into the modern medical period.

Christian attitudes

The coming of Christian civilization in the Latin West initiated a major paradigm shift in the history of hysteria. From the fifth to the thirteenth centuries, naturalistic pagan construals of the disease were increasingly displaced by supernatural formulations. In the writings of St Augustine, human suffering, including organic and mental illness, was perceived as a manifestation of innate evil consequent upon original sin. Hysteria in particular, with its shifting and highly dramatic symptomatology, was viewed as a sign of possession by the devil. The hysterical female was now interpreted alternately as a victim of bewitchment, to be pitied, or the devil's soulmate, to be despised. No less powerfully mythopoetic than the classical image of the disease, the demonological model envisioned the hysterical anesthesias, mutisms, and convulsions as stigmati diaboli or marks of the devil.

This sea change in thinking about the disorder brought with it changes in treatment. The elaborate pharmacopeia of ancient times was now replaced by supernatural invocations — prayers, incantations, amulets, and exorcisms. Furthermore, with the demonization of the diagnosis came the widespread persecution of the afflicted. During the late medieval and Renaissance periods, the scene of interrogation of the female hysteric shifted from the hospital and sick bed to the church and the court room, which now became the loci of spectacular interrogations. Official manuals for the detection of witches, often virulently misogynistic, supplied instructions for the detection, torture, and at times execution of the witch/hysteric.

Early medical theories

The late Renaissance, which witnessed the height of the witchcraft craze in continental Europe, also produced in reaction several substantial efforts to renaturalize the idea of hysteria. Advances in understanding the structure and function of the human nervous system provided a new model for many previously baffling nervous disorders, including hysteria. Gynecological and demonological theories waned; in their place, new neurocentric theories combined with fashionable mechanical and iatrochemical ideas from the physical and chemical sciences.

In Britain, which dominated medical thinking about the subject during the early modern period, the neuroanatomist Thomas Willis propounded a theory according to which an excess of ‘animal spirits’ was released from the brain and carried by the nerves to the spleen and abdomen, where it entered the bloodstream to circulate through the body. Robert Whytt thought the disorder was caused by a weakness of the nerve fibres, and William Cullen attributed it to a slowing of the nervous fluids through the brain. In the 1680s, the famous physician Thomas Sydenham hypothesized that the condition was caused by an imbalance in the distribution of the animal spirits between body and mind, brought on by sudden and violent emotions, such as anger, fear, grief, and love. English and Scottish medical literature about hysteria during the seventeenth and eighteenth centuries offers memorable clinical descriptions of classic hysterical phenomena, including the hysterical attack in the arched back position and the clavus hystericus, or feeling of a nail being driven into the forehead. In the 1700s in particular, in France and Britain, these ideas provided the basis for an entire ‘nervous culture’ in which men and women of high society fashioned themselves as refined, sensible, and civilized.

The 1800s brought a multiplication of theories about hysteria, including new uterine, neurological, and characterological models. During the final quarter of the century — hysteria's famous heroic age — the centre of attention shifted to France. In the 1880s, the Parisian clinical neurologist Jean–Martin Charcot, formulated a comprehensive, neurogenic model of ‘the great neurosis’. For Charcot, hysteria was strictly a dysfunction of the central nervous system, akin to epilepsy, syphilis, and other neurological diseases. Like these ailments, hysterical neuropathy, he held, was the result of a lesion of an undetermined structural or functional nature that could be studied through the methods of pathological anatomy and that resulted from defective heredity. Charcot lavished his attention on the descriptive neurosymptomatology of his cases. He developed a schematized, four-stage model of the hysterical fit, and he mapped a series of ‘hysterogenic zones’ onto the body of the hysteric.

Emergence of psychology

Socially, the late nineteenth century witnessed the appearance of ‘the Victorian nervous invalid.’ Significant numbers of men and women modelled their sickness behaviour on the contemporary teachings of hysteria doctors like Charcot until these nervous disorders seemed to reach epidemic proportions. Culturally, the character of the nervous invalid figured prominently in fictional prose writing of the time. By the time of Charcot's death in 1893, medical thinking about hysteria had reached an impasse. The search for the missing lesion of hysteria, and therefore for its somatic basis, remained fruitless. As a consequence, physicians turned to alternative conceptualizations of these mysterious, multiform disorders, including to psychological theories.

The psychologization of the hysteria concept a century ago is associated foremostly with Sigmund Freud, who worked in Vienna in the late Victorian mould of the private nerve specialist. Psychoanalysis began as a theory and therapy of hysteria. In a series of essays and monographs written between 1885 and 1900, Freud radically reconceptualized hysteria. He reversed the previously projected direction of mind–body causality, claiming that hysteria was a psychological disease with quasi-physical symptoms. Furthermore, Freud placed the emphasis on the psychological mechanism of hysterical symptom formation. According to his formulation, hysterogenesis rests in the repression of traumatic memories. These memories are usually remote in the emotional past of the individual and invariably libidinal, or sexual, in content. Because these remembrances are painful or unpleasant, they are unable to find conscious psychological expression. Freud postulated further that the negative emotional energy, or ‘strangulated affect’, associated with these memories is then unconsciously converted into the somatic manifestations of hysteria. Moreover, in this process of hysterical conversion, symptoms are not arbitrary and meaningless phenomena but complex symbolizations of repressed psychological experiences. In psychoanalytic psychology, the body is the physical field on which the wishes, anxieties, and traumas of the hysteric are dramatized.

Recent trends

The most consequential development in the history of hysteria in the last century was the rapid decline in the medically recorded incidence of the disorder. In part, this diminution is due to the liberalization of gender norms, permitting freer social, emotional, and sexual expression among women. It also traces to a process whereby many symptoms and behaviours formerly constitutive of hysteria have been reassigned to other diagnostic categories, including organic disorders, psychoses, and psychoneuroses. Since the 1970s, hysteria as an independent diagnostic entity has been deleted from the official manuals of medical diagnosis. In Anglo–American psychiatry, much of what was characterized as conversion hysteria in psychodynamic psychiatry is now classified under the more scientific-sounding rubric of somatization disorder. An exception to this rule can be found in French medicine, which continues widely to employ the concept of hysteria in psychological theory and clinical practice.

Conclusions

Several conclusions may be drawn from hysteria's long and colourful past. First, it is most likely impossible in this instance to project a single, unchanging pathological entity through history. The clinical descriptions lumped under the heading through the ages have been highly diverse, and the theoretical structures for understanding these behaviours have varied enormously. Many different morbid phenomena have no doubt been gathered under the umbrella of ‘hysteria’. Second, what has been called hysteria in the past may clearly be read as a kind of cross-gender portraiture in the field of medicine. To a very great extent, ‘the history of hysteria’ consists of a body of writing by men about women. Feminist-informed scholars of the later twentieth century emphasize that this literature often depicts, in the descriptive language of the clinic, features of the opposite sex that male élites in past patriarchal societies found irritating, incomprehensible, or unmanageable. Hysteria theory literally embodies these ideas, attitudes, and biases.

A third conclusion concerns the distinctive blend of science, sexuality, and sensationalism in the story of hysteria. Given the extravagant physical symptoms, emotional outbursts, and erotic undercurrents involved in many cases carrying this label, it is hardly surprising that hysterics have often been forced into lurid roles and vaudevillian performances. In short, hysteria has been the vehicle for astute clinical observation, pioneering neuropathological research, and brilliant psychological theorizing; it has equally been the site of much misogyny, sensationalism, and mistreatment. Fourth and finally, hysteria's history may be read as an ongoing attempt to theorize the mind–body relation within the medical sciences. Is hysteria fundamentally a psychological disorder with physical manifestations; an organic disease with mental and emotional epiphenomena; or some inseparable intermixture of the two? Studying the subject through the ages has involved a continual, relational reconfiguring of the role of psyche and soma in human mental life. Within the clinical human sciences, hysteria represents the shifting and diversely theorized interface between the history of the body and the history of the mind.

Some scholars have argued that hysteria is the oldest and most important category of neurosis in recorded medical history. Similarly, perhaps no non-fatal disorder boasts a richer metaphorical and mythological past. Over the centuries and in many different cultures, thinking and writing about the subject has mirrored dominant attitudes about health and sickness, the natural and the supernatural, the sexual and the spiritual, mind and body, and masculinity and femininity. Now, it appears, hysteria — construed variously as a term, theory, and behaviour — is vanishing. Given the remarkable cultural indispensability of the concept in the past, readers can only speculate on what will take its place in the future.

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Hysteria

HYSTERIA

Hysteria refers both to a personality type and to a cluster of psychoneurotic symptom formations. Its manifestations—dramatic, physical, and affective—may be viewed as an attempt to express and symbolize a psychosexual conflict and, at the same time, to defend against acknowledging that conflict. Symptoms range from mental anxiety and phobia to the physical signs of conversion disorder.

The term derives from hustera, the Greek word for uterus, and was historically considered a female disorder. Writings on hysteria date to ancient Egypt and the Kahun papyrus (ca.1900 BCE), which described the disturbances caused by the "wandering uterus" that manifested as symptoms in various parts of the body. Greco-Roman doctors continued to associate hysteria with the uterus and to treat it as a female complaint. From the end of antiquity through the Middle Ages and the Inquisition, recourse to supernatural explanations made it possible to consider hysteria a form of demoniacal possession or witchcraft. The theatrical and contagious nature of hysterical symptoms may have been at the root of phenomena such as the "possessed" nuns of Loudun, the convulsionaries of Saint-Médard, and the Salem witches. Hysterics and their putative victims were often burned at the stake.

Identification of hysteria as a distinct entity dates to 1870, when Jean Martin Charcot, a doctor at the largest hospice in France, the La Salpêtrière, segregated hysterics from other mental patients for purposes of research and investigation.

As a concept hysteria acquired several meanings:

Conversion hysteria was a convulsive attack characterized by paralysis, muscular contractions and bodily contortions, visual disturbances, including hallucination, pain and anesthesia, and so on.

As a psychoneurosis, studied by psychoanalysis, it was manifested by various symptoms and inversion of affect. Thus, Sigmund Freud's patient Dora experienced sexual excitation not as desire but as disgust, a hysterical displacement of a genital sexual conflict (1905e).

The term "hysteric" also qualifies, pejoratively, a certain type of distaff personality in which prominent use is made of dramatization, emotional exuberance, colorful and exaggerated language, continuous erotization, and seductiveness.

Finally, in everyday language, hysteria is the stuff of "emotional outburst" and "making a scene."

Broadly speaking, conversion hysteria led to the discovery of psychoanalysis as a method of understanding and treating psychopathological symptoms. Freud, who famously attended clinical demonstrations by Charcot, was struck by the indifference that hysterical patients displayed toward their suffering. Although for a time he suspected traumatic childhood seduction to be at the root of hysteria, he came to view such patients suffering "mainly from reminiscences" (1895d, p. 7)—that is, from a repressed traumatic event that remained mnemonically unintegrated, and could therefore only be expressed by conversion—through a corporeal memory, so to speak.

The death of his father in 1897 and subsequent self-analysis with Wilhelm Fliess led Freud to the discovery of his childhood passion for his mother and of his hostile feelings toward his father. Although the Oedipus complex did not appear as part of Freudian theory until later, he abandoned the theory of traumatic seduction; his key discovery was the notion of infantile sexuality, together with the importance of fantasy as a force that was both creative and disorganizing. At the same time he developed the concept of psychic defense
and discovered in dreams and dream-work a link with hysteria.

In psychoanalytic theory, a hysterical crisis might be thought of as the embodiment of a dream. Its symptoms included the same mechanisms of condensation, displacement, symbolization, and disguise through censorship. Hysteria expressed a conflict that, incapable of being elaborated mentally, is translated in altogether enigmatic fashion into physical symptoms. The associative method of psychoanalysis could be used to identify the fantasies and symbolic pathways within it. Thus Freud described a hysterical woman who, with one hand, tore off her clothes, and with the other, held them against her body, simultaneously expressing the struggle between impulse and defense, enacting in effect a sexual scene in which she represented partners of both sexes (1908a). Hysterical neurosis and hysterical relationships involve identification, constant repression, and counter-cathexis that uses the Other as the theater of conflict.

Due to the absence of an organic lesion and the tendency for symptoms to disappear without a trace, as mysteriously as they came, hysterical conversion represented a provocative challenge to medicine. In general, hysterics have historically triggered irritation, accusations of lying and malingering, and rejection.

Hysteria has always defied medicine and the social order because sexuality is mixed up in it—in particular, female sexuality and the associated desire for sexual pleasure. Freud, in 1937, referred to the "repudiation of femininity" (p. 252) in both sexes as "bedrock," a stumbling block because of the mental association of the female with castration. Symptomatically, hysteria is an illness of repudiated femininity. More specifically, the anxiety that leads to this repudiation reflects the considerable libidinal energy required by the constant pressure of libido, a pressure that may be destructive of the ego.

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Hysteria

Gale Encyclopedia of Medicine, 3rd ed.
COPYRIGHT 2006 Thomson Gale

Hysteria

Definition

The term "hysteria" has been in use for over 2,000 years and its definition has become broader and more diffuse over time. In modern psychology and psychiatry, hysteria is a feature of hysterical disorders in which a patient experiences physical symptoms that have a psychological, rather than an organic, cause; and histrionic personality disorder characterized by excessive emotions, dramatics, and attention-seeking behavior.

Description

Hysterical disorders

Patients with hysterical disorders, such as conversion and somatization disorder experience physical symptoms that have no organic cause. Conversion disorder affects motor and sensory functions, while somatization affects the gastrointestinal, nervous, cardiopulmonary, or reproductive systems. These patients are not "faking" their ailments, as the symptoms are very real to them. Disorders with hysteric features typically begin in adolescence or early adulthood.

Histrionic personality disorder

Histrionic personality disorder has a prevalence of approximately 2-3% of the general population. It begins in early adulthood and has been diagnosed more frequently in women than in men. Histrionic personalities are typically self-centered and attention seeking. They operate on emotion, rather than fact or logic, and their conversation is full of generalizations and dramatic appeals. While the patient's enthusiasm, flirtatious behavior, and trusting nature may make them appear charming, their need for immediate gratification, mercurial displays of emotion, and constant demand for attention often alienates them from others.

Causes and symptoms

Hysterical disorders

Hysteria may be a defense mechanism to avoid painful emotions by unconsciously transferring this distress to the body. There may be a symbolic function for this, for example a rape victim may develop paralyzed legs. Symptoms may mimic a number of physical and neurological disorders which must be ruled out before a diagnosis of hysteria is made.

Histrionic personality disorder

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV ), individuals with histrionic personality possess at least five of the following symptoms or personality features:

a need to be the center of attention

inappropriate, sexually seductive, or provocative behavior while interacting with others

rapidly changing emotions and superficial expression of emotions

vague and impressionistic speech (gives opinions without any supporting details)

easily influenced by others

believes relationships are more intimate than they are.

Diagnosis

Hysterical disorders frequently prove to be actual medical or neurological disorders, which makes it important to rule these disorders out before diagnosing a patient with hysterical disorders. In addition to a patient interview, several clinical inventories may be used to assess the patient for hysterical tendencies, such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2 ) or the Millon Clinical Multiaxial Inventory-III (MCMI-III). These tests may be administered in an outpatient or hospital setting by a psychiatrist or psychologist.

Treatment

Hysterical disorders

For people with hysterical disorders, a supportive healthcare environment is critical. Regular appointments with a physician who acknowledges the patient's physical discomfort are important. Psychotherapy may be attempted to help the patient gain insight into the cause of their distress. Use of behavioral therapy can help to avoid reinforcing symptoms.

Histrionic personality disorder

Psychotherapy is generally the treatment of choice for histrionic personality disorder. It focuses on supporting the patient and on helping develop the skills needed to create meaningful relationships with others.

Prognosis

Hysterical disorders

The outcome for hysterical disorders varies by type. Somatization is typically a lifelong disorder, while conversion disorder may last for months or years. Symptoms of hysterical disorders may suddenly disappear, only to reappear in another form later.

Histrionic personality disorder

Individuals with histrionic personality disorder may be at a higher risk for suicidal gestures, attempts, or threats in an effort to gain attention. Providing a supportive environment for patients with both hysterical disorders and histrionic personality disorder is key to helping these patients.

JEAN MARTIN CHARCOT (1825–1893)

Jean Martin Charcot was born to a carriage maker on November 29, 1825,in Paris, France. Charcot attended the University of Paris, earning his medical degree in 1853. In 1860, he accepted a position at the university as a professor of pathological anatomy until 1862, when he was named senior physician at the Salpêtrière, a hospital for the treatment of mental illness.

Charcot's research and work on psychoneuroses and hysterical disorders untimately helped to dispell the belief that hysteria was a disorder found only in women. Charcot also explored the possibility that physiological abnormalities of the nervous system played a part when behavioral problems were exhibited. He became known for his ability to diagnose and locate these abnormalities of the central nervous system. Finally, Charcot's most notable contribution to the field of psychiatry was his successful use of hypnotism in the diagnosis and treatment of hysteria. He found that, while hypnotized, the patient recalled details, which were not readily available to the individual in a conscious state. In addition, Charcot found that the therapist could more easily influence the hypnotized patient during therapy. In 1882, Charcot presented his research findings to the French Academy of Sciences with favorable results.

Charcot was a prolific writer and a talented artist. Between 1888 and 1894, his complete works were compiled into nine volumes. His most noted work Lectures on the Diseases of the Nervous System was published in 1877. Charcot died on August 16, 1893.

KEY TERMS

Conversion disorder— A psychological disorder that alters motor or sensory functions. Paralysis, blindness, anesthesia (lack of feeling), coordination or balance problems, and seizures are all common symptoms of the disorder.

Somatization disorder— The appearance of physical symptoms in the gastrointestinal system, the nervous system, the cardiopulmonary system, or the reproductive system that have no organic cause.

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hysteria

The Columbia Encyclopedia, 6th ed.

Copyright The Columbia University Press

hysteria (hĬstĕr´ēə), in psychology, a disorder commonly known today as conversion disorder, in which a psychological conflict is converted into a bodily disturbance. It is distinguished from hypochondria by the fact that its sufferers do not generally confuse their condition with real, physical disease. Conversion disorder is usually found in patients with immature, histrionic personalities who are under great stress. Women are affected twice as frequently as men. Symptoms, which are largely symbolic and which relieve the patient's anxiety, include limb paralysis, blindness, or convulsive seizures. The specific physical disorder usually does not correspond to the anatomy; e.g., an entire limb may be paralyzed rather than a specific group of muscles. The person may also appear to be unconcerned about the illness, a condition French psychiatrist Pierre Janet called la belle indifference (1929). At the end of the 19th cent., great advances were made in the understanding and cure of hysteria by the recognition of its psychogenic nature and by the use of hypnotism to influence the hysteric patient, who is known to have a high degree of suggestibility. The Austrian physician Josef Breuer, the French psychologists J. M. Charcot and Pierre Janet, and Austrian psychiatrist Sigmund Freud were pioneers in the investigation of hysteria through hypnosis. Freud concluded that hysterical symptoms were symbolic representations of a repressed unconscious event, accompanied by strong emotions that could not be adequately expressed or discharged at the time. Instead, the strong effect associated with the event was diverted into the wrong somatic channels (conversion), and the physical symptom resulted. Psychoanalysis has had reasonable success in helping patients suffering from conversion disorder.

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hysteria

hys·te·ri·a
/ hiˈsterēə; -ˈsti(ə)rēə/
•
n.
exaggerated or uncontrollable emotion or excitement, esp. among a group of people:
the mass hysteria that characterizes the week before Christmas. ∎ Psychiatry
a psychological disorder (not now regarded as a single definite condition) whose symptoms include conversion of psychological stress into physical symptoms (somatization), selective amnesia, shallow volatile emotions, and overdramatic or attention-seeking behavior. The term has a controversial history as it was formerly regarded as a disease specific to women.

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hysteria

hysteria In psychology, a group of disorders characterized by emotional instability, dissociation, hallucinations and the presence of physical symptoms of illness with no physiological cause. Hysteria is no longer used as a diagnostic term.Leading researchers in this field have included Jean Martin Charcot, Pierre Janet and Sigmund Freud.

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